=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659847721
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | WALLACE ROBERTO ASCENCIO LICSW
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/16/2018
-----------------------------------------------------
Last Update Date | 12/30/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7401 W HOOD PL STE 117
-----------------------------------------------------
City | KENNEWICK
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 99336-3400
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 509-596-6230
-----------------------------------------------------
Fax | 509-221-1455
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7401 W HOOD PL STE 117
-----------------------------------------------------
City | KENNEWICK
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 99336-3400
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 509-596-6230
-----------------------------------------------------
Fax | 509-221-1455
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | LW61216281
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------